Rationale and Early Experience with Prophylactic Placement of Mesh to Prevent Parastomal Hernia Formation after Ileal Conduit Urinary Diversion and Cystectomy for Bladder Cancer

Parietal complications after cystectomy: Incisional and parastomal hernia, epidemiology and risk factors

INTRODUCTION

Incisional and parastomal hernias are frequent complications after cystectomy. The aim of our study was to define their incidence, identify risk factors related to the patient and the surgical technique, and identify means of prevention.

MATERIAL

This was a multicenter, retrospective study, analyzing clinical and radiological data from 521 patients operated on for cystectomy between January 2010 and December 2020.

RESULTS

In total, 521 patients, 471 men and 50 women, mean age 68.8years, were included. Thirty-one patients (6.6%) presented with an evisceration. Risk factors were a history of evisceration (OR: 14.1; 95% CI: [3-66]; P=0.0008), COPD (OR: 3.5; 95% CI: [1.3-9 .4]; P=0.0119), ischemic heart disease (OR: 4; 95% CI: [1. 6-10]; P=0.0036), and split-stitch closure (OR: 3.1; 95% CI: [1.065-8.9]; P=0.0493). Fifty-one patients (9.9%) presented with an incisional hernia. Risk factors were a history of COPD (OR: 4, 95% CI: [2.1-7.6]; P<0.001) and postoperative pulmonary infection (OR: 5.3; 95% CI: [1.05-26.4]; P=0.0079). Seventy-nine patients (15.28%) had a parastomal hernia. Overweight was a risk factor (OR: 2.3; 95% CI: [1.3-4.5]; P=0.0073).

CONCLUSION

Patients who are overweight or have pulmonary comorbidities are at greater risk of developing parietal complications after cystectomy.

LEVEL OF EVIDENCE

III.

Repair of parastomal hernia after Bricker procedure: retrospective consecutive experience of a tertiary center

BACKGROUND

Ileal conduit parastomal hernias (ICPHs) are frequent after radical cystectomy with ileal conduit urinary diversion, but their management is debated. This study aimed to review the results of ICPH repair according to Sugarbaker or Sandwich techniques, with special interest in ICPH recurrence and urological complications.

METHODS

The authors reviewed a consecutive series of patients undergoing ICPH repair between January 2014 and December 2020. Primary endpoints were ICPH recurrences at clinical exam and cross-sectional abdominal computed tomography (CT) scans. Secondary endpoints were any other complications possibly related to the ICPH repair.

RESULTS

Twenty-three patients underwent ICPH repair surgery (16 Sugarbaker and 7 Sandwich techniques) during the study period. Sixteen patients underwent a primary laparoscopic approach. All but one patient underwent at least one abdominal CT during the follow-up. Median clinical and CT scan follow-up times were 57 and 50.5 months, respectively. Clinical and CT ICPH recurrence rates were 4.5% and 13% at 5 years, respectively. Eighteen patients (78%) suffered no urological complications during the follow-up period, but three patients (13%) needed redo surgery on the urinary ileal conduit.

CONCLUSION

The modified Sugarbaker or Sandwich techniques might be considered as promising techniques for ICPH repair with a low rate of recurrence. The urological complications, and particularly the ileal conduit-related issues, need to be evaluated in further studies. Controlled and prospective data are required to compare the Sugarbaker and Sandwich techniques to the Keyhole approach for ICPH repairs.

Development and preliminary evaluation of a novel procedure for creation of an ileal conduit stoma aimed at preventing parastomal hernia

OBJECTIVES

Our previous study suggested that the operative procedure is critical for the development of parastomal hernia. We developed a novel procedure for the creation of an ileal conduit stoma to prevent parastomal hernia. Herein we evaluate the efficacy and safety of the procedure.

METHODS

A total of 113 Japanese patients underwent radical cystectomy and ileal conduit diversion for bladder cancer from January 2017 through December 2021 at our institution. After excluding those with incomplete data, 103 patients consisting of 46 (44.7%) with the conventional procedure and 57 (55.3%) with the novel procedure were consecutively enrolled. The main points of the novel procedure are as follows: (1) the passage of the ileal conduit is ≤2.4 cm in diameter in principle; (2) the posterior rectus sheath and peritoneum are vertically incised 2 cm laterally from the middle of the stoma site to make an oblique passage for the ileal conduit; and (3) the anterior rectus sheath and posterior rectus sheath with peritoneum are fixed to the ileal conduit separately.

RESULTS

Radiography-based parastomal hernia was observed in 11 patients (10.7%) with a median follow-up of 22.0 months. The incidences of parastomal hernia were 3.5% and 19.6% in the novel and the conventional procedure groups, respectively (p = 0.011). The former had a significantly lower cumulative incidence of parastomal hernia (p = 0.008, log-rank test). No specific complications associated with the procedure were observed.

CONCLUSIONS

The results of the preliminary cohort study suggest that the novel procedure is safe and effective for the prevention of parastomal hernia.

Parastomal Hernia Following Ileal Conduit: Incidence, Risk Factors, and Health-Related Quality of Life

PURPOSE

The purpose of this study was to measure the incidence of parastomal hernia (PH) after radical cystectomy and ileal conduit. Secondary aims were the identification of risk factors for PH and to compare the health-related quality of life (QOL) between patients with and without PH.

DESIGN

Retrospective review of medical records combined with cross-sectional administration of the QOL instrument and telephone follow-up.

SUBJECTS AND SETTING

The study sample comprised 219 patients who underwent radical cystectomy and ileal conduit for urothelial cancer between February 2014 and December 2018. The study setting was Peking University First Hospital (Beijing, China).

METHODS

Demographic and pertinent clinical data, including development of PH, were gathered via the retrospective review of medical records. Participants were also asked to complete the traditional Chinese language version of the City of Hope Quality of Life-Ostomy Questionnaire (C-COH). Multiple linear regression analysis was used to identify the effect of PH on C-COH scores. Logistic regression analysis was used to identify risk factors for PH development.

RESULTS

At a median follow-up of 34 months (IQR = 21-48), 43 of 219 (19.63%) patients had developed a PH. A body mass index (BMI) indicating overweight (OR = 3.548; 95% CI, 1.562-8.061; P = .002), a prior history of hernia (OR = 5.147; 95% CI, 1.195-22.159; P = .028), and chronic high abdominal pressure postdischarge (CHAP-pd) (OR = 3.197; 95% CI, 1.445-7.075; P = .004) were predictors of PH after operation. There was no significant difference between C-COH scores of patients with or without PH. No significant differences were found when participants with PH were compared to those without PH on 4 factors of the C-COH: physical scores (β= .347, P = .110), psychological scores (β= .316, P = .070), spiritual scores (β=-.125, P = .714), and social scores (β= .054, P = .833).

CONCLUSION

Parastomal hernia is prevalent in patients undergoing radical cystectomy and ileal conduit urinary diversion. Overweight, hernia history, and CHAP-pd were predictors of PH development. No significant differences in QOL were found when patients with PH were compared to those without PH.

Assessment of Urostomy Parastomal Herniation Forces Using Incisional Prevention Strategies with an Abdominal Fascia Model

Background

Approximately 10 000 patients undergo cystectomy/ileal conduit annually in the USA, of whom over 70% subsequently develop a parastomal hernia (PSH). Still, no well-established "best" practice for stoma creation to prevent a PSH exists.

Objective

To measure the relationship between incision size/type/material and axial tension force (ATF) as a surrogate for herniation force, using several models to mimic abdominal fascia.

Design setting and participants

Abdominal fascia models included silicone membrane, ex vivo porcine, and embalmed human cadaveric fascia. A dynamometer pulled a Foley catheter (20 mm/min) with the balloon inflated to 125% incision (linear, cruciate, and circular) diameter using a motorized positioning system. The maximum ATF before herniation was recorded. The study was repeated in unused silicone/tissue for suture reinforcement. We evaluated silicone, ex vivo porcine, and human abdominal fascia.

Intervention

Incision sizes (1-3 cm) in 0.5-cm increments were evaluated in silicone. A 3-cm incision was used in porcine/human tissue.

Outcome measurements and statistical analysis

ATF for herniation was recorded/compared across incision types/sizes using Mann-Whitney U and Kruskal-Wallis tests as appropriate, with α = 0.05.

Results and limitations

Linear incision ATF was significantly greater than cruciate and circular incisions. A cruciate incision had significantly greater ATF than a circular incision. In cadaveric tissue, incisions were significantly greater for linear (34.5 ± 12.8 N) versus cruciate (15.3 ± 2.9 N, p = 0.004) and for cruciate versus circular (p = 0.023) incisions. Results were similar in ex vivo porcine fascia and silicone. Reinforcement with a suture significantly increased ATF in all materials/incision sizes/types. The ex vivo nature is this study's main limitation.

Conclusions

This study suggests that urostomy fascial incision type may influence ATF required for herniation. Linear incisions may be preferable. Urostomy reinforcement may significantly increase ATF required for a PSH. These data may help establish best practices for PSH risk reduction.

Patient summary

The results of this study illustrate that urostomy fascia incision type may influence the force required to create a parastomal hernia. Linear incisions may be preferable.

Prophylactic parastomal mesh sublay at the time of ileal conduit: surgical technique

OBJECTIVE

To demonstrate the surgical technique for prophylactic mesh placement in the sublay position during ileal conduit creation because literature suggests that prophylactic mesh placement at the time of cystectomy may reduce the risk of parastomal hernias with low risk of mesh-related complications. Parastomal hernias are one of the most common complications following ileal conduit construction and occur in 17-65% of patients undergoing cystectomy with urinary diversion. Review of our institutions data demonstrated a high incidence of hernias associated with ileal conduits, which have substantial burden to patients, surgeons, and the healthcare system.

METHODS

This is a retrospective chart review of data from a single surgeon who performed cystectomy with ileal conduit for 12 patients with bladder cancer between 1/2021-3/2022 at our institution. These dates were chosen based on the timing of availability of literature suggesting a benefit from prophylactic mesh placement. Preliminary data was analyzed determine the incidence of parastomal hernia and mesh-related complications.

RESULTS

A total of 12 patients underwent cystectomy with ileal conduit between 1/2021-3/2022 at our institution. Eleven patients (92%) had prophylactic mesh placed during their procedure. Median follow up was 5.4 months (0.8-8 months). Two patients (17%) developed a parastomal hernia which was detected clinically and/or radiographically. The hernias occurred in patients with mesh and within 6 months of cystectomy. One patient had stomal stenosis eventually requiring surgical revision. There were no mesh infections or mesh removals.

CONCLUSIONS

Parastomal hernias are a common and morbid complication of ileal conduit urinary diversion. Our early experience demonstrates that the procedure is straightforward, adds little time to the surgical procedure, and is associated with a low complication rate. Our experience is too small and follow up too short to confirm that the results of the randomized trial can be matched at our center.

Parastomal hernias after cystectomy and ileal conduit urinary diversion: surgical treatment and the use of prophylactic mesh: a systematic review

Background

Parastomal hernia after ileal conduit urinary diversion is an underestimated and undertreated clinical entity, which heavily impairs patients’ quality of life due to symptoms of pain, leakage, application or skin problems. As for all gastrointestinal stomata the best surgical repair technique has yet to be determined. Thereby, surgery for ileal conduit parastomal hernias poses some specific perioperative challenges. This review aims to give an overview of current evidence on the surgical treatment of parastomal hernia after cystectomy and ileal conduit urinary diversion, and on the use of prophylactic mesh at index surgery in its prevention.

Methods

A systematic review was performed according to PRISMA-guidelines. The electronic databases Embase, PubMed, Cochrane Library, and Web of Science were searched. Studies were included if they presented postoperative outcomes of patients undergoing surgical treatment of parastomal hernia at the ileal conduit site, irrespective of the technique used. A search was performed to identify additional studies on prophylactic mesh in the prevention of ileal conduit parastomal hernia, that were not identified by the initial search.

Results

Eight retrospective case-series were included for analysis, reporting different surgical techniques. If reported, highest complication rate was 45%. Recurrence rates varied highly, ranging from 0 to 80%. Notably, lower recurrence rates were reported in studies with shorter follow-up. Overall, available data suggest significant morbidity after the surgical treatment of ileal conduit parastomal hernias. Data from five conference abstracts on the matter were retrieved, and systematically reported. Regarding prophylactic mesh in the prevention of ileal conduit parastomal hernia, 5 communications were identified. All of them used keyhole mesh in a retromuscular position, and reported on favorable results in the mesh group without an increase in mesh-related complications.

Conclusion

Data on the surgical treatment of ileal conduit parastomal hernias and the use of prophylactic mesh in its prevention is scarce. Given the specific perioperative challenges and the paucity of reported results, more high-quality evidence is needed to determine the optimal treatment of this specific surgical problem. Initial results on the use of prophylactic mesh in the prevention of ileal conduit parastomal hernias seem promising.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01509-y.

Extraperitonealization of ileal conduit reduces parastomal hernia after cystectomy and ileal conduit diversion

OBJECTIVE

Parastomal hernia (PSH) is a common complication of ileal conduit diversion after radical cystectomy. Novel surgical techniques for preventing PSH formation are needed. We aimed to evaluate surgical technique of extraperitonealizing the ileal conduit (modified ileal conduit) for preventing PSH.

METHODS

A retrospective analysis of 375 consecutive patients who underwent ileal conduit after cystectomy at the Sun Yat-sen University Cancer Center between January 1, 2000 and June 31, 2019 was conducted. 214 patients had modified ileal conduit diversion and 161 patients conventional ileal conduit (Bricker) diversion. The demographic and clinicopathologic characteristics of patients in the 2 groups were compared using the t test and Chi square test. Univariable and multivariable Cox regression analyses were used to predict the risk of PSH formation.

RESULTS

The 2 groups were comparable in regard to all demographic and clinicopathologic variables. The incidence of PSH diagnosed by CT scan was 7.5% in the modified group and 21.1% in the conventional group (P < 0.001). High BMI and history of prior abdominal surgery was identified by univariable analysis as risk factors of PSH formation. Multivariable analyses revealed that technique of extraperitonealizing ileal conduit significantly reduced incidence of PSH in patients with or without risk factors of PSH formation (OR = 0.29, 95% CI 0.16-0.54, P < 0.001).

CONCLUSIONS

Technique of extraperitonealizing ileal conduit appeared to be effective in reducing PSH formation after ileal conduit diversion.

Urostomal ileal conduit complications in association with abdominal wall mesh implantation

OBJECTIVE

Parastomal hernia (PH) in association with an ileal conduit is a common complication that is difficult to treat. Mesh reinforcement has been suggested to improve outcomes; either as prophylaxis or for treatment of a parastomal hernia during abdominal wall reconstruction.

PATIENTS AND METHODS

A retrospective study was performed in consecutive patients subjected to mesh implantation between 2000 and 2016 having a concurrent or previous ileal conduit reconstruction. Postoperative and late urostomal complications, as well as hernia occurrence, were ascertained by a chart review of patients' records.

RESULTS

A total of 25 patients were included of whom 13 (52%) developed either a urostomal complication, a PH, or both. Complications were caused by mesh erosion in four patients, of which three were diagnosed more than five years after surgery. Four patients developed a urostomal stenosis. One out of eight patients with urostomal complications were subjected to a new ileal conduit reconstruction and another four to other types of revisional surgery.

CONCLUSIONS

Every second patient with an ileal conduit developed either a local urostomal complication, a PH, or both after abdominal wall mesh reconstruction. A careful and cautious attitude towards the use of mesh in patients with an ileal conduit is suggested.

Keyhole versus Sugarbaker techniques in parastomal hernia repair following ileal conduit urinary diversion: a retrospective nationwide cohort study

BACKGROUND

Previous research on parastomal hernia repair following ileal conduit urinary diversion is limited. This nationwide cohort study aims to present the results of keyhole and Sugarbaker techniques in parastomal hernia repair in the setting of ileal conduit urinary diversion.

METHOD

All patients in this cohort underwent primary elective parastomal hernia repair following ileal conduit urinary diversion in four university hospitals and one central hospital in Finland in 2007-2017. Retrospective clinical data were collected from patient registries to compare keyhole and Sugarbaker parastomal hernia repair techniques. The primary outcome was parastomal hernia recurrence during the follow-up from primary surgery to the last confirmed follow-up date of the patient. The secondary outcomes were reoperations during the follow-up and complication rate at 30 days' follow-up.

RESULTS

The results of 28 hernioplasties were evaluated. The overall parastomal hernia recurrence rate was 18%, the re-operation rate was 14%, and the complication rate was 14% during the median follow-up time of 30 (21-64) months. Recurrence rates were 22% (4/18) after keyhole repair and 10% (1/10) after Sugarbaker repair. Re-operation rates referred to keyhole repair were 22% and Sugarbaker repair 0% during follow-up. The majority of reoperations were indicated by recurrence. Complication rates were 17% after keyhole and 10% after Sugarbaker repair during the 30 days' follow-up.

CONCLUSION

The results of parastomal hernia repair in the setting of ileal conduits are below optimal in this nationwide cohort comparing keyhole to Sugarbaker repair in elective parastomal hernia repair. Nonetheless, the Sugarbaker technique should be further studied to confirm the encouraging results of this cohort in terms of recurrence.

Incidence and risk factors of parastomal hernia after radical cystectomy and ileal conduit diversion: a systematic review and meta-analysis

Background

Our aim is to report the incidence and risk factors of parastomal hernia (PH) after radical cystectomy (RC) and ileal conduit (IC) diversion with a cumulative analysis.

Methods

Various databases, including PubMed, the Cochrane Library, Embase and Web of Science, were retrieved electronically and manually to identify eligible studies from inception to August 20, 2020. Two reviewers independently searched the above databases and selected the studies using prespecified standardized criteria. The Newcastle-Ottawa Scale (NOS) was used to assess the risk of bias in the included studies, and the data was completed by STATA version 14.2.

Results

Fifteen studies were included in the final analysis. A pooled analysis of eight studies representing 1,878 patients reported the incidence of overall radiographic PH was 23% (95% CI: 17–29%). The 1-year PH incidence rate and 2-year incidence rate of RC and IC were 14% (95% CI: 6–22%) and 26% (95% CI: 14–38%), respectively. A pooled analysis of nine studies reported the incidence of clinically evident PH was 15% (95% CI: 10–19%). PH-related symptoms were reported in six studies, and the pooled result was 29% (95% CI: 24–33%), and a pooled analysis of ten studies showed that 20% (95% CI: 11–28%) of patients required surgical repair. However, it’s noteworthy that among symptomatic PH patients undergoing surgical repair, the pooled analysis of five studies showed that up to 26% (95% CI: 16–36%) of patients suffered PH recurrence. The most frequent risk factor was body mass index (BMI). Patients with BMI ≥22.9 kg/m² experienced 2.92-fold higher risk of PH than their counterparts [hazard ratio (HR): 2.92; 95% CI: 1.65–5.19].

Conclusions

Our findings indicated that the PH incidence rate after RC and IC was significantly higher in radiographic evaluation than that of clinical examination, and the recurrence of repairment is considerable for patients requiring reconstruction.

Ileal conduit or orthotopic neobladder: selection and contemporary patterns of use

PURPOSE OF REVIEW

The orthotopic neobladder and ileal conduit are the two most commonly utilized urinary diversions among patients undergoing radical cystectomy. Although orthotopic diversion offers several advantages, only 20% of patients nationally receive this diversion, with decreasing utilization over time. The purpose of this article is to review advantages of each diversion type and considerations in patient selection, review trends in diversion utilization and perioperative and functional outcomes, and examine recent studies evaluating methods of optimizing diversion selection and patient satisfaction and outcomes.

RECENT FINDINGS

Decreasing utilization of orthotopic diversion has coincided with the increasing utilization of minimally invasive surgical techniques. A multicentre robotic series demonstrated a higher incidence of high-grade complications with intracorporeal diversion, reflecting the learning-curve associated with this technique. Patient satisfaction with urinary diversion is associated with informed decision-making and goal alignment. Ongoing quality of life studies is aiming to identify predictors of patient satisfaction with the selected urinary diversion and may help guide patient counselling.

SUMMARY

Given the potential advantages of orthotopic diversion, its decreasing use is a concerning trend. Elucidating patient goals and informed decision-making are critical to patient satisfaction. A patient-centred approach should be used when selecting the type of urinary diversion for a given patient.

Preventing Parastomal Hernia After Ileal Conduit by the Use of a Prophylactic Mesh: A Randomised Study

BACKGROUND

Parastomal hernia (PSH) after urinary diversion with ileal conduit is frequently a clinical problem.

OBJECTIVE

To investigate whether a prophylactic lightweight mesh in the sublay position can reduce the cumulative incidence of PSH after open cystectomy with ileal conduit.

DESIGN, SETTING, AND PARTICIPANTS

From 2012 to 2017, we randomised 242 patients 1:1 to conventional stoma construction (n = 124) or prophylactic mesh (n = 118) at three Swedish hospitals (ISRCTN 95093825).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was clinical PSH, and secondary endpoints were radiological PSH assessed in prone position with the stoma in the centre of a ring, parastomal bulging, and complications from the mesh.

RESULTS AND LIMITATIONS

Within 24 mo, 20/89 (23%) patients in the control arm and 10/92 (11%) in the intervention arm had developed a clinical PSH (p = 0.06) after a median follow-up of 3 yr, corresponding to a hazard ratio of 0.45 (confidence interval 0.24-0.86, p = 0.02) in the intervention arm. The proportions of radiological PSHs within 24 mo were 22/89 (25%) and 17/92 (19%) in the two study arms. During follow-up, five patients in the control arm and two in the intervention arm were operated for PSH. The median operating time was 50 min longer in patients receiving a mesh. No differences were noted in proportions of Clavien-Dindo complications at 90 d postoperatively or in complications related to the mesh during follow-up.

CONCLUSIONS

Prophylactic implantation of a lightweight mesh in the sublay position decreases the risk of PSH when constructing an ileal conduit without increasing the risk of complications related to the mesh. The median surgical time is prolonged by mesh implantation.

PATIENT SUMMARY

In this randomised report, we looked at the risk of parastomal hernia after cystectomy and urinary diversion with ileal conduit with or without the use of a prophylactic mesh. We conclude that such a prophylactic measure decreased the occurrence of parastomal hernias, with only a slight increase in operating time and no added risk of complications related to the mesh.

Incidence and risk factors of parastomal hernia after ileal conduit diversion in Japanese population

OBJECTIVES

To determine risk factors influencing the incidence of parastomal hernia (PH) associated with ileal conduit (IC).

METHODS

A total of 194 Japanese patients who underwent IC diversion followed by regular postoperative radiographic follow-up from 2005 through 2016 were enrolled. The diagnosis of PH was determined by computed tomography (CT) for patients with and without related symptoms. The cumulative incidence of PH was assessed by the Kaplan-Meier method. The log-rank test and a multivariate Cox proportional hazards model were used to evaluate risk factors associated with the incidence of PH.

RESULTS

PH was observed in 20 patients (10.3%) after a median follow-up of 25.5 months. Of the 20 patients, three were symptomatic. The cumulative incidences were 3.6%, 10.1% and 15.1% at 1, 2 and 5 years after operation, respectively. The median body mass index (BMI) was 23.1 kg/m² (IQR 20.4-24.6). The BMI and diameter of the passage through the rectus abdominis muscle for the IC (DPRAM) were significant predictors for PH (p = 0.04 and p < 0.001, respectively). In proportional hazards regression analysis, DPRAM ≥ 2.4 cm was the only independent risk factor for developing PH (HR 10.94, 95% CI 3.66-32.64).

CONCLUSIONS

The incidence of PH in the current Japanese series was relatively low. Even in the population with low BMI, higher BMI might have an impact on incidence of PH. Moreover, DPRAM was also significantly associated with the incidence, suggesting that the operative procedure for creation of the passage is critical for future development of PH.

The European Hernia Society classification applied to the rare cases of parastomal hernia after ileal conduit urinary diversion: a retrospective cohort of 96 patients

INTRODUCTION

To determine the incidence and classification of parastomal hernia (PH) following ileal conduit urinary diversion and to identify risk factors for PH development.

METHODS

We performed a retrospective review of our cystectomy database which includes benign and malignant cases from 2011-2016. Patients with an abdominal CT at 24 ± 2 months post-operation were included. PH were classified according to the European Hernia Society (EHS) system. Regression analyses were performed on variables associated with parastomal hernia.

RESULTS

A total of 96 patients were included in the study. The incidence of PH on CT is 20.2% at one year and 28.1% at two years. Using the EHS classification, the majority of PH was small (≤ 5 cm), but up to 50% were associated with a concomitant incisional hernia. On multivariable analysis, (C-index = 0.71), obesity was associated with a higher risk of PH (OR = 2.8, 95% CI 1.06-7.42, p = 0.04), whereas prior tobacco use was associated with a lower risk of PH at 2 years (OR = 0.23, 95% CI 0.09-0.63, p < 0.01).

CONCLUSIONS

Hernia after ileal conduit is common with radiographic rates approaching 30% at two years, with obesity being an independent risk factor. The relationship between prior tobacco use and a lower hernia rate may be limited to this study but presents an opportunity for future investigation. No difference in PH rates were observed between open and minimally invasive surgery and between intracorporeal and extracorporeal conduits.

Prophylactic mesh used in ileal conduit formation following radical cystectomy: a retrospective cohort

PURPOSE

Given the difficulty of durable repairs, there is continued interest in hernia prevention. One emerging prevention technique for parastomal hernias is prophylactic mesh placement, whereby mesh is inserted during the index procedure as hernia prophylaxis. We evaluated our experience using prophylactic mesh when creating an ileal conduit.

METHODS

We retrospectively reviewed patients undergoing robotic cystectomy with ileal conduit from 6/2010 to 8/2017. Patient demographics and operative/perioperative outcomes were documented. We evaluated hernia recurrence using postoperative computed tomography scanning or physical exam. Prophylactic mesh was inserted at the operating surgeon's discretion using a synthetic resorbable or biologic mesh.

RESULTS

During the study period, 38 patients underwent robotic-assisted cystectomy with ileal conduit formation. Average patient age was 68 years, with 28 (74%) male and 35 (92%) Caucasian patients. Three patients (8%) required conversion to open, and one patient (3%) had a concomitant colorectal resection. Thirty-one (88%) patients had postoperative computed tomography scanning. Prophylactic mesh was used in 18 patients (47%) in a retrorectus position. Of these, 15 (83%) patients had synthetic resorbable mesh and 3 (17%) patients had biologic mesh. At average follow-up of 21 months, one hernia recurred (5%) in a patient without mesh placement at the time of ileal conduit. At an average follow-up of 11 months, there have been no recurrences and no mesh-related complications in the prophylactic mesh group.

CONCLUSIONS

Using prophylactic mesh in ileal conduit, creation is feasible and may decrease the parastomal hernia formation rate. Further study of using synthetic resorbable and biologic meshes for hernia prophylaxis is warranted.

Incisional hernia prevention and use of mesh. A narrative review

Incisional hernias are a very common problem, with an estimated incidence around 15-20% of all laparotomies. Evisceration is another important problem, with a lower rate (2.5-3%) but severe consequences for patients. Prevention of both complications is an essential objective of correct patient treatment due to the improved quality of life and cost savings. This narrative review intends to provide an update on incisional hernia and evisceration prevention. We analyze the current criteria for proper abdominal wall closure and the possibility to add prosthetic reinforcement in certain cases requiring it. Parastomal, trocar-site hernias and hernias developed after stoma closure are included in this review.

Surgical Complications of Urinary Diversion

Urinary diversion (UD) with an intestinal segment has significant risks of short- and long-term complications. With modern reporting criteria, understanding of the true prevalence and spectrum of these complications has improved. Methods to minimize early postoperative complications include enhanced recovery pathways, restricted intraoperative fluid protocols, and referral to high-volume centers. With long-term follow-up after UD, the risk of complications steadily rises. Late surgical complications include ureterointestinal anastomotic strictures, urolithiasis, and stomal issues. Patients with UDs require close surveillance to monitor for anatomic, infectious, and metabolic complications and surgeons who perform UD should be aware of the risk and timing of postoperative complications.

Natural History and Predictors of Parastomal Hernia after Robot-Assisted Radical Cystectomy and Ileal Conduit Urinary Diversion

PURPOSE

We investigated the prevalence of and variables associated with parastomal hernia and its outcomes after robot-assisted radical cystectomy and ileal conduit creation for bladder cancer.

MATERIALS AND METHODS

We retrospectively reviewed the records of patients who underwent robot-assisted radical cystectomy at our institution. Parastomal hernia was defined as the protrusion of abdominal contents through the stomal defect in the abdominal wall on cross-sectional imaging. Parastomal hernia was further described in terms of patient and hernia characteristics, symptoms, management and outcomes. The Kaplan-Meier method was used to determine time to parastomal hernia and time to surgery. Multivariate stepwise logistic regression was done to evaluate variables associated with parastomal hernia.

RESULTS

A total of 383 patients underwent robot-assisted radical cystectomy and ileal conduit creation. Of the patients 75 (20%) had parastomal hernia, which was symptomatic in 23 (31%), and 11 (15%) underwent treatment. Median time to parastomal hernia was 13 months (IQR 9-22). Parastomal hernia developed in 9%, 23% and 32% of cases at 1, 2 and 3 years, respectively. Patients with parastomal hernia had a significantly higher body mass index (30 vs 28 kg/m², p = 0.02), longer overall operative time (357 vs 340 minutes, p = 0.01) and greater blood loss (325 vs 250 ml, p = 0.04). On multivariate analysis operative time (OR 1.25, 95% CI 1.21-3.90, p <0.001), a fascial defect 30 mm or greater (OR 5.23, 95% CI 2.32-11.8, p <0.001) and a lower postoperative estimated glomerular filtration rate (OR 2.17, 95% CI 1.21-3.90, p = 0.01) were significantly associated with parastomal hernia.

CONCLUSIONS

Symptoms develop in approximately a third of patients with parastomal hernia and 15% will require surgery. The risk of parastomal hernia plateaued after postoperative year 3. Longer operative time, a larger fascial defect and lower postoperative kidney function were associated with parastomal hernia.